500385 Rev. 03/2012
Group/Association - Short Term Disability Benefits
Life Insurance Company of North America
Connecticut General Life Insurance Company
CIGNA Life Insurance Company of New York
Great-West Healthcare Administered by CIGNA
DIVISION
Date:
REASONIF YES, DATE
Yes No
Yes No
NAME OF EMPLOYER / ASSOCIATION
EMPLOYER / ASSOCIATION
Connecticut General Life Insurance Company
Life Insurance Company of North America
Group/Association -
Short Term Disability Benefits
Print: Signature:
HAS EMPLOYEE/MEMBER BEEN TERMINATED?
IF YES, DATE
EMPLOYER’S / ADMINISTRATOR’S CERTIFICATION
PAID THRU DATEGROSS WEEKLY AMOUNT DATE BEGANBENEFIT
LAST DAY WORKED DATE RETURNED TO WORK PREMIUM PAID THROUGH DATE % OF INSURED’S
CONTRIBUTION TO PREMIUM
# of Hours:
IF YES, DOES THIS LIFE INSURANCE POLICY CONTAIN A WAIVER OF PREMIUM PROVISION?
PLEASE LIST ALL BENEFITS THAT THE INSURED IS RECEIVING OR ELIGIBLE TO RECEIVE AS A RESULT OF HIS/HER DISABILITY (E.G. SALARY CONTINUANCE, SICK PAY, STATE
DISABILITY, WORKERS’ COMPENSATION, ETC.).
IS THIS INDIVIDUAL COVERED UNDER A LIFE INSURANCE POLICY PROVIDED BY A CIGNA UNDERWRITING COMPANY?
YES NO
YES NO
M F
CIGNA Life Insurance Company of New York
Great-West Healthcare Administered by CIGNA
TO BE COMPLETED BY THE EMPLOYER / ADMINISTRATOR
NAME OF EMPLOYEE/ASSOCIATION MEMBER (Last Name) (Middle Initial) DATE OF BIRTH SEXSOCIAL SECURITY NO.(First Name)
CIGNA Group Insurance
Life Accident Disability
..
Management
Pre-Tax Basis Post-Tax Basis
EMPLOYEE’S / MEMBER’S CONTRIBUTIONS WERE MADE ON:
If Yes, Attach CopyYes No
WAS INSURANCE ISSUED ON THE BASIS OF A STATEMENT OF PHYSICAL CONDITION?
BASIC EARNINGS PER WEEK
Salaried
Hourly
Union Local #_________
Non-Union
PLEASE CHECK THE APPROPRIATE BLOCKS REGARDING THE INSURED’S EMPLOYMENT STATUS.
OCCUPATIONPOLICY NO.
( )
TELEPHONE #(Zip Code)(State)ADDRESS (Street) (City)
Exempt
Non-Exempt
Hrs./wk
DATE OF LAST CHANGE IN EARNINGS DATE HIRED / MEMBER OF ASSOCIATION EFFECTIVE DATE OF INSURANCE
Non-Management
Supervisory
Non-Supervisory
Full-Time
Part-Time
Page 2 of 5
HAS EMPLOYEE/MEMBER BEEN LAID OFF? REASON
500385 Rev. 03/2012
MAIL OR FAX TO:
TELEPHONE #(Zip Code)(State)ADDRESS (Street) (City)
( )
FRAUD WARNING: Any person who, knowingly and with intent to defraud any insurance company
or other person: (1) files an application for insurance or statement of claim containing any materially
false information; or (2) conceals for the purpose of misleading, information concerning any material
fact thereto, commits a fraudulent insurance act. For residents of the following states, please see
the last page of this form: California, Colorado, District of Columbia, Florida, Kentucky,
Maryland, Minnesota, New Jersey, New York, Oregon, Pennsylvania, Rhode Island,
Tennessee, Texas or Virginia.
Clear Fields
CIGNA Group Insurance
P.O. Box 709015
Dallas, TX 75370-9015
Facsimile: (800) 642-8553
Yes No
Yes No
Yes No
DATES OF SERVICE - INCLUDE DATE OF NEXT APPOINTMENT (IF PREVIOUS FORM SUBMITTED TO THIS CARRIER, YOU NEED SHOW ONLY DATES SINCE LAST REPORT).
DATE
REMARKS: WE ARE INTERESTED IN ANY INFORMATION THAT WOULD BE HELPFUL TO YOUR PATIENT FOR EVALUATION OF THIS CLAIM.
IF STILL DISABLED, DATE PATIENT SHOULD BE ABLE TO RETURN TO WORK.
DATE PERFORMED
INPATIENT OUTPATIENT
THRUIF "YES", CONFINED FROMHAS PATIENT BEEN HOSPITAL CONFINED?
DATE PATIENT FIRST CONSULTED YOU
FOR THIS CONDITION.
DATE SYMPTOMS FIRST APPEARED OR
ACCIDENT HAPPENED.
IS CONDITION DUE TO INJURY OR SICKNESS ARISING OUT OF PATIENT’S
EMPLOYMENT?
COMPLICATIONS
ESTIMATED DATE OF CONFINEMENTAPPROXIMATE DATE PREGNANCY
COMMENCED
IF "YES", PLEASE PROVIDE THE FOLLOWING INFORMATION IF APPLICABLE.
Yes No
Yes No
DIAGNOSIS AND CONCURRENT CONDITIONS, INCLUDING ICD-9 OR DSM IV-TR CODE.
PLEASE LIST ALL BENEFITS YOU ARE RECEIVING OR ELIGIBLE TO RECEIVE UNDER ANY OTHER GROUP INSURANCE, GOVERNMENT PLAN OR AUTOMOBILE MANDATORY NO-FAULT
COVERAGE.
PLEASE DESCRIBE YOUR JOB DUTIES IN DETAIL. WHAT PERCENT OF YOUR JOB REQUIRES PHYSICAL LABOR?
BENEFIT DATE BEGANGROSS WEEKLY AMOUNT PAID THRU DATE
TO BE COMPLETED BY ATTENDING PHYSICIAN
IS CONDITION DUE TO PREGNANCY?
DATE OF DELIVERY TYPE OF DELIVERY
PATIENT STILL UNDER YOUR CARE FOR
THIS CONDITION?
HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION? IF "YES", WHEN AND DESCRIBE
NATURE OF SURGICAL PROCEDURE, IF ANY
PATIENT WAS CONTINUOUSLY TOTALLY DISABLED - (UNABLE TO WORK)
NAME AND ADDRESS OF HOSPITAL
From: Thru:
PHYSICIAN’S NAME (PRINT) SIGNATURE
ARE YOU COVERED UNDER A LIFE INSURANCE POLICY PROVIDED BY A CIGNA UNDERWRITING COMPANY?
IF YES, DOES THIS LIFE INSURANCE POLICY CONTAIN A WAIVER OF PREMIUM PROVISION?
TELEPHONEZIP CODESTATE OR PROVINCESTREET ADDRESS
TAX IDENTIFICATION NUMBERDEGREE SOCIAL SECURITY NUMBER
CITY OR TOWN
YES
YES NO
NO
HAVE YOU HAD THE SAME OR SIMILAR CONDITION IN THE PAST? IF SO, PLEASE
DESCRIBE IN DETAIL.
LIST STATES IN WHICH YOU MAY BE LIABLE FOR FILING TAX RETURNS
TO WORK
DATE FIRST UNABLE TO WORKDATE OF ACCIDENT OR
BEGINNING OF SICKNESS
DESCRIBE IN YOUR OWN WORDS WHAT IS WRONG WITH YOU (IF ACCIDENT, DESCRIBE
CIRCUMSTANCES AND ADVISE WHETHER IT OCCURRED AT WORK).
DATE YOU PLAN TO RETURN
TO BE COMPLETED BY THE CLAIMANT
PLEASE TYPE OR PRINT BE SURE TO ANSWER ALL QUESTIONS - FAILURE TO DO SO MAY DELAY YOUR CLAIM.
USE SEPARATE PIECE OF PAPER TO COMPLETE ANSWERS IF NECESSARY
PLEASE LIST ANY HOSPITALS, CLINICS OR PHYSICIANS THAT TREATED YOU FOR YOUR ILLNESS OR INJURY.
NAME TREATMENT PERIODCOMPLETE ADDRESS
DATE SIGNEDSIGNATURE OF AUTHORIZED REPRESENTATIVE
THIS IS TO CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
The issuance of this blank is not an admission of the existence of any insurance nor does it recognize the validity of any claim and is without
prejudice to the Company’s legal rights in the premises.
Page 3 of 5
500385 Rev. 03/2012
IF NOT, PLEASE PROVIDE THE NAME OF YOUR MEDICAL INSURANCE CARRIER
YES NOHAVE YOU ELECTED CIGNA HEALTHCARE MEDICAL INSURANCE THROUGH YOUR EMPLOYER?
Page 4 of 5
..
CIGNA Group Insurance
Life Accident Disability
Disclosure Authorization
AUTHORIZATION
I authorize any physician, medical professional or other health care provider, hospital or other medical facility;
pharmacy; health plan; other medically related entity; rehabilitation professional; vocational evaluator; employee
assistance plan; insurance company, reinsurer, health maintenance organization, third party administrator, broker or
other insurance service provider, or similar entity; the Medical Information Bureau; the Association of Life Insurance
Companies, which operates the Health Claims Index and the Disability Income Record System; government
organization or agency, including the Social Security Administration; financial institution, accountant or tax preparer;
consumer reporting agency; and employer or group policyholder that has information about my health, prescriptions,
financial, earnings or employment history, or other insurance claims and benefits to provide access to or copies of this
information to the Plan and to any individual or entity who provides services to or insurance benefits on behalf of the
Plan, including but not limited to the requesting company(ies) named below ("Company"). To the extent I may be
eligible for governmental benefits similar to or that coordinate with those available to me under the Plan, I also authorize
disclosure of information necessary to apply for or determine my eligibility for such benefits to the relevant government
agency and/or vendor providing application assistance.
For any claim for insurance benefits, this authorization is valid for the shorter of 24 months or the duration of my claim.
For all other permitted disclosures, this authorization is valid for one (1) year from the date below. I am entitled to a
copy of this authorization and a photographic or electronic copy of it is as valid as the original.
I understand that any information obtained with this authorization will be used for evaluating and administering my
coverage, including any claim for benefits, or otherwise providing services related to or on behalf of the Plan, which may
include, but is not limited to assisting me in returning to work and Plan administration. With respect to governmental
benefits similar to or that coordinate with benefits available to me under the Plan, I understand that the information will
be used to help determine my eligibility for any such benefits and may include assisting me in applying for the benefits. I
understand that the information disclosed under this authorization is subject to redisclosure and may no longer be
protected by certain federal regulations governing the privacy of health information, although it will continue to be
protected by other applicable privacy laws and regulations.
I understand that I do not have to give this authorization. If I choose not to give the authorization - or if I later revoke -
I understand that the Plan, insurers, or other providers of services or benefits related to the Plan who rely on this
authorization may not be able to evaluate or administer my request for Plan benefits, coverage or services and that my
request for Plan benefits, coverage or services may be denied as a result. I may revoke this authorization by sending
written notice to the Claim Manager handling my claim.
Claimant’s Name:
Information about my health may relate to any disorder of the immune system including but not limited to HIV and AIDS;
use of drugs or alcohol; and mental and physical history, condition, advice or treatment, but does not include
psychotherapy notes.
NOTE: This authorization is designed to comply with HIPAA and relates to information necessary to administer
coverage and services under your employer’s employee health and welfare plan(s) ("the Plan") and similar or
coordinating governmental benefits. You are not required to sign the authorization, but if you do not, the Plan, insurers
or other providers of services or coverage under the Plan may not be able to process your request for Plan benefits,
coverage or services.
Company Names: Life Insurance Company of North America, CIGNA Life Insurance Company of New York, CIGNA
Worldwide Insurance Company, Great-West Life & Annuity Insurance Company, First Great-West Life & Annuity
Insurance Company, New England Life Insurance Company, Alta Health & Life Insurance Company and Connecticut
General Life Insurance Company.
(Date of Birth)(Print Name)
(Claimant’s Signature) (Date Signed)
Guardian, or Conservator, please attach a copy of the document granting authority.
(indicate relationship). If Power of Attorney Designee,
I signed on behalf of the claimant as
500385 Rev. 03/2012
Page 5 of 5
500385 Rev. 03/2012
Colorado Residents: It is unlawful to knowingly provide false, incomplete or misleading facts or
information to an insurance company for the purpose of defrauding or attempting to defraud the
company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete or
misleading facts or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to settlement or award payable from
insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance
is guilty of a crime and may be subject to fines and confinement in prison.
Texas Residents: Any person who knowingly presents a false or fraudulent claim for the payment
of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
New Jersey: Any person who knowingly files a statement of claim containing any false or
misleading information is subject to criminal and civil penalties.
New York Residents: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim containing any
materially false information, or conceals for the purpose of misleading, information concerning any
fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject
to a civil penalty not to exceed $5000 and the stated value of the claim for each such violation.
Oregon Residents: Any person who knowingly and with intent to defraud any insurance company
or other person: (1) files an application for insurance or statement of claim containing any materially
false information; or, (2) conceals for the purpose of misleading, information concerning any
material fact, may have committed a fraudulent insurance act.
Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits application or files a claim containing a false or deceptive
statement may have violated state law.
District of Columbia Residents: WARNING: It is a crime to provide false or misleading information
to an insurer for the purpose of defrauding the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant.
Kentucky Residents: Any person who knowingly and with intent to defraud any insurance
company or other person files a statement of claim containing any materially false information or
conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime.
Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any
insurer files a statement of claim or an application containing any false, incomplete or misleading
information is guilty of a felony of the third degree.
Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim
for payment of a loss or benefit or who knowingly and willfully presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Pennsylvania Residents: Any person who, knowingly and with intent to defraud any insurance
company or other person, files an application for insurance or statement of claim containing any
materially false information, or conceals for the purpose of misleading, information concerning any
fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person
to criminal and civil penalties.
Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
California Residents: Any person who knowingly presents a false or fraudulent claim for the
payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
IMPORTANT CLAIM NOTICE
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome